i

Experiences of Agency nurses regarding their

placement in private hospitals in East London,

Eastern Cape

By

Jennifer Muller

Submitted in fulfilment of the requirements of the

degree of

MCur (Nursing Science)

In the

Faculty of Science and Agriculture

University of Fort Hare

Supervisor: Prof. E. Seekoe

ii

DECLARATION

I declare that the entirety of the work contained herein is my own, that I am the

authorship owner thereof and that I have not previously in its entirety or in part

submitted it for obtaining any qualification at any institution.

Signature…………

iii

DEDICATION

This dissertation is dedicated to my husband and children, Bruce, Joshua and

Nathan.

This work is further dedicated to all agency nurses and all nurses in the Eastern

Cape.

iv

ACKNOWLEDGEMENT

I should like to acknowledge God by whose grace my spirit is renewed every

day

I should like to express my sincere thanks to my supervisor, Prof. Seekoe,

whose knowledge and passion for research is inspiring and motivating. For

your guidance and support, thank you.

My husband, Bruce, and my sons, Joshua and Nathan, thank you for your

patience, support and motivation to continue this journey. Thank you for

encouraging me to continue, when I wanted to give up. Without your support

and your belief in me, I could not have finished this project.

Helen Bunt, thank you for your assistance and help, for your advice and

encouragement to complete this task, and for the time spent discussing this

research.

Thank you to the agency for allowing me to conduct the research with agency

staff.

To all nurses I interviewed: Thank you for giving me your time and trusting me

with your experiences in the hospital. Your input was valuable.

To all my working colleges who encouraged me and supported me through

this journey: Thank you for all the hugs that I needed.

Thanks to the language editor for editing my work and her professional input.

Thanks to GMRDC for funding my thesis.

Thanks to the technical editor for her professional input.

v

List of Figures

Figure 1: Conceptual framework for the study....................................................................9

List of Tables

Table 2.1: Creswell’s steps in data analysis .................................................................... 22

Table 2.2: Example of significant statements and formation of meaning.................... 27

Table 2.3: Strategies of trustworhiness ............................................................................ 31

Table 3.1: Demographic profile of agency nurses .......................................................... 37

Table 3.2: Themes generated from the interviews ......................................................... 41

vi

Table of Contents

CHAPTER 1: INTRODUCTION AND PROBLEM STATEMENT.....................................1

1.1 INTRODUCTION AND BACKGROUND ...................................................................1

1.2 PROBLEM STATEMENT.............................................................................................5

1.3 AIM OF STUDY.............................................................................................................7

1.3.1 Research Question ....................................................................................................7

1.3.2 Research Objectives .................................................................................................7

1.4 SIGNIFICANCE OF THE STUDY ..............................................................................8

1.5 CONCEPTUAL FRAMEWORK ..................................................................................8

1.6. DEFINITION OF TERMS......................................................................................... 13

1.6.1 Nursing Agency....................................................................................................... 13

1.6.1 Registered Nurse................................................................................................... 14

1.6.1 Enrolled Nurse ........................................................................................................ 14

1.6.4 Enrolled nursing assistant ..................................................................................... 14

1.6.5 Agency Nurse.......................................................................................................... 15

1.6.6 Private hospitals ...................................................................................................... 15

1.7 CHAPTER OUTLINE .................................................................................................... 16

1.8 CONCLUSION ............................................................................................................ 16

CHAPTER 2: RESEARCH METHODOLOGY ................................................................. 17

2.1 INTRODUCTION ........................................................................................................ 17

2.2 AIM OF STUDY ......................................................................................................... 17

2.2.1 Research question .................................................................................................. 17

2.2.2 Research objectives ............................................................................................... 18

2.3 RESEARCH DESIGN AND METHODS ................................................................. 18

2.3.1 Research Approach ................................................................................................ 19

2.3.2 Research Design .................................................................................................... 19

2.4 POPULATION AND SAMPLING ............................................................................ 20

2.4.1 Population ................................................................................................................ 20

2.4.2Sampling ................................................................................................................... 20

2.4.3 Criteria for inclusion ................................................................................................ 22

2.4.4 Criteria for exclusion............................................................................................... 22

vii

2.5 RESEARCH INSTRUMENT ..................................................................................... 22

2.5.1 Pre Test .................................................................................................................... 23

2.6 DATA COLLECTION ................................................................................................. 23

2.7 DATA ANALYSIS ....................................................................................................... 25

2.8 ETHICAL CONSIDERATIONS ................................................................................ 28

2.9 TRUSTWORTHINESS .............................................................................................. 31

2.10 CONCLUSION.......................................................................................................... 35

CHAPTER 3: ANALYSIS AND INTERPRETATION OF RESEARCH FINDINGS..... 36

3.1 INTRODUCTION....................................................................................................... 36

3.2 SECTION A ................................................................................................................. 37

3.3 SECTION B................................................................................................................. 40

3.3.3 Theme 2: Growth through experience................................................................. 45

3.3.4 Theme 3: Disappointment of not been made permanent ................................. 51

3.3.5 Theme 4: Challenges encountered by agency nurses ..................................... 53

3.3.6 Theme 5: Environment of working conditions ................................................... 60

3.3.7 Theme 6: Sense of security .................................................................................. 63

3.3.8 CONCLUSION ........................................................................................................ 68

CHAPTER 4: CONCEPTUALISATION............................................................................. 69

4.1 INTRODUCTION........................................................................................................ 69

4.2 SELECTING AND REVIEWING OF LITERATURE.............................................. 69

4.3 FINDINGS FROM LITERATURE ............................................................................ 69

4.3.1 The background to agency work .......................................................................... 69

4.3.2 Reasons for agency work ...................................................................................... 72

4.3.3 Aspects to consider as reasons of doing agency work..................................... 77

4.3.3.1 Employment opportunities, financial benefit, flexibility and other advantages

of doing agency work ....................................................................................................... 77

4.3.4 Challenges encountered with the use of agency staff ...................................... 79

4.3.4.1 Challenges encountered by the hospitals ....................................................... 80

4.3.4.2 Challenges encountered by the agency nurses ............................................. 83

4.4 STRATEGIES ALREADY IMPLEMENTED TO IMPROVE THE WORKING

ENVIRONMENT ............................................................................................................... 86

4.5 CONCLUSION ............................................................................................................ 90

viii

CHAPTER 5: DISCUSSION, IMPLICATIONS, LIMITATIONS AND

RECOMMENDATIONS ....................................................................................................... 91

5.1 INTRODUCTION ........................................................................................................ 91

5.2 DISCUSSION ............................................................................................................. 91

5.2.1 Demographic data .................................................................................................. 91

5.2.2 Themes generated from interviews concerning the experiences of the agency

nurses about placement in the private hospitals ......................................................... 92

5.2.2.1. Reasons for doing agency work ...................................................................... 92

5.2.2.2. Growth through experience .............................................................................. 94

5.2.2.3. Disappointment of not been made permanent .............................................. 95

5.2.2.4. Challenges encountered by the agency staff ................................................ 96

5.2.2.5 Enviroment of working conditions.................................................................... 98

5.2.2.6 Sense of security................................................................................................ 99

5.3 IMPLICATIONS ........................................................................................................ 101

5.4 LIMITATIONS OF THE STUDY ............................................................................. 102

5.5 RECOMMENDATIONS ........................................................................................... 103

5.6 SUMMARY................................................................................................................ 106

5.7CONCLUSION........................................................................................................... 107

APPENDIX 1 ................................................................................................................... 109

APPENDIX 2 ................................................................................................................... 110

APPENDIX 3 .................................................................................................................. 111

APPENDIX 4 ................................................................................................................... 112

APPENDIX 5 ................................................................................................................... 113

APPENDIX 6 ................................................................................................................... 114

APPENDIX 7 ................................................................................................................... 116

APPENDIX 8 ................................................................................................................... 118

APPENDIX 9 ................................................................................................................... 119

APPENDIX 10 ................................................................................................................. 127

REFERENCES................................................................................................................ 128

1

CHAPTER 1: INTRODUCTION AND PROBLEM STATEMENT

1.1 INTRODUCTION AND BACKGROUND

This study is focused on the experiences of agency nurses in private hospitals in

East London, Eastern Cape. The worldwide phenomena of the shortage of nursing

staff and increased costs of health care has led to the use of agency staff as a large

part of the workforce in health care hospitals. Shortage of nursing staff remains a

problem worldwide. In the United States of America, the US Government predicts

that it will be short of between 800 000 and one million nurses by 2020. Additional

nursing jobs of about 233 000 will open only to about 200 000 candidates who

passed the Registered nurse licensing procedure. (Advisory Board Company and

Kaiser Family Foundations, 2009:1).

A study conducted by Manias, Aitken, Peerson, Parker and Wong (2003:269) reports

that the shortage of staff has led to increased reliance on agency nurses. Despite

the continued use and considerable cost of agency nurses, little is known regarding

the agency nurses’ perceived relationships with the agencies, hospitals and

permanent staff and of their professional status. Peerson, Aitken, Manias, Parker

and Wong (2002:504) have supported the notion that agency nursing is a poorly

understood and an under-researched phenomenon. Despite the considerable costs

and possible benefits of using agency nurses, not much research has been

undertaken about the nature of agency nursing from different perspectives, including

those of hospital and agency managers.

Expenditure on agency nursing staff in the United Kingdom by the National Health

Service (NHS) has escalated. This is demonstrated by the 2001-2002 National

Health Service trust in Wales spending 1.8% of the nursing costs on agency nursing

staff in one year and the cost rising to 2.5% in the following year (Massey, Esain &

Wallis, 2007:912).

2

The general Australian workforce is becoming increasingly reliant on agency staff

due to the diminishing of full-time jobs and the rise in part-time jobs since the

recession of 1991-1992. This pattern is also seen in Western countries such as

America and the United Kingdom (Peerson et al., 2002:505). The excessive costs

of health service adopting a 100% staffing model has created the use of agency

nursing to help meet fluctuating and unpredictable health care demands in Australia

and overseas; agency staff are used to meet the shortfalls in staff-patient ratios

(Peerson et al., 2002:505).

Hurst & Smith (2011:287) agree that agency nurse staffing form a large part of the

health service in the UK and state that this was unlikely to change because of

recruitment and retention problems, high absenteeism, and staff wanting to work

casually. In their study, they identified three types of agency nurses: A bank nurse –

the hospital’s own employees or those supplied by NHS Professionals, who work

when required, usually at short notice; agency nurses provided by commercial

organisations, who are equally flexible but less familiar with the ward patients and

procedures; and permanent ward staff working paid overtime.

In South Africa, this also remains a problem in public and private institutions. The

World Health Organization (WHO) states that the minimum ratio for nurses to

population is 200:100 000 or 500 people per nurse. According to South African

Nursing Council statistics of nursing manpower as at the end of 2008, South Africa

has 437 nurses for every 100 000 people. This assumed that all nurses registered

with SANC are working in South Africa at the time. Therefore, if the assumed

number of staff not working in South Africa is subtracted, the ratio can increase to

between 600 and 678 people per nurse (WHO, 2006).

Joubert (2009:2) shows that a shortage of nurses contributes to deaths in hospitals

in South Africa that would otherwise have been avoidable. The use of agency staff is

becoming an appropriate means of providing cost-effectiveness and flexibility to

staffing needs. It is cost effective to use agency staff on an irregular basis.

According to Collier (2011:2), nurses leaving their jobs add to the shortage in South

Africa and 10% loss of staff in the general area and 15% in specialised nursing area

has been reported. There also appears to be a growing trend for professional nurses

3

to prefer casual employment instead of permanent status. South Africa has shown

considerable increase in the use of agency staff; the staff component of hospital

nursing staff comprises 49% in agency nurses. Research by Massey et al.

(2009:913), Peerson et al. (2002:274), Ball, and Pike (2006:25) found similar

reasons for nursing staff working through an agency, for instance greater flexibility

which give nurses the opportunity to choose off duties enabling them to balance

personal life with work life. Some stated they needed flexibility for health reasons,

studying and fulfilling family responsibilities. The advantage of working through the

agency is that nurses have more autonomy and independence. One of the reasons

is variety, which gives nurses an opportunity to work in different areas of hospitals.

Nurses also have the opportunity to choose the area in which they want to work.

Financial gain is another reason for agency work, for permanent staff to top up their

salaries and have extra income.

In the Buffalo City Local Service area, the private institutions, occupational health

clinics and retirement homes use agency staff. The government institutions have not

used agency staff yet, although they also experience a shortage of staff (Seanda

Healthcare, Service Level Agreement, 2013:3).

The disadvantages the agency staff experience are that the pay rate is lower and

there is uncertainty of pay, including a lack of available pension or holiday pay. Work

is not always available, which makes it difficult to plan, aggravated by cancellations,

which also affect planning. Some also believe that career development can be

affected by the lack of access to training and professional development. Some

nurses experienced isolation and not being part of a team as a disadvantage.

Unfamiliarity with environment and lack of confidence in work if not orientated to the

unit is another disadvantage (Massey et al., 2009:913). A study done by Collier

(2011:48) indicates that agency nurses experience challenges such as lack of a

sense of belonging and recognition. Mixed feelings regarding being accepted and

belonging to a team affects their work for they seemed to lack support due to the

business and workloads of the units. While agency staff receives inadequate

orientation, staff who work shifts in the same ward indicate that there is collaboration

between themselves and permanent staff and they feel respected and have a sense

of belonging (Collier, 2011:48).

4

Nurses are not always notified long in advance of being required for duty. This puts

patients at risk, as mistakes then can be made. According Hurst and Adam

(2011:289), the most worrying aspect of using agency staffing is the quality issue.

An Alaskan hospital study showed that high workload and rising agency staffing

increased medication errors. Hurst and Adam’s (2011:12) research agreed and

concluded that wards with higher workloads and fewer permanent staff are justified

in using agency staff, but service quality may be affected as a result. In a study

conducted by Manias et al. (2003:459) for which interviews were done with directors

of nursing of two long-term care facilities about their use of agency nurses, the

Directors agreed that agency nurses performed necessary nursing duties, including

administration of medication, charting and direct resident care. Because of Financial

constraints, often make it necessary for nurses to complement their salaries,

therefore they “moonlight” and the problem here is that the nurses then do not have

the adequate rest needed during time off to be productive and may even work more

hours than which is approved by the Employment Act and Labour Relations Act.

(Basic Conditions of Employment Act of 1997:96; Labour Relations Act, No. 66 of

1995, as amended). This can place the patients in danger as it may lead to an

increase in incidents and mistakes and decreases quality care.

Nurses make use of working through the agency for different reasons: 1. Staff

employed in another organisation may work in the private sector in their off time; this

is often referred to as moonlighting. The reason for this practice, is financial gain; it is

to top up salaries. 2. Staff only employed by the agency and working in private

hospitals; this may involve newly qualified staff who are unable to find permanent

work. 3. Staff employed by the private hospital but work over time through the

agency. This practice is often followed by staff who need extra money and cannot

wait until the end of the month for salaries. Agencies are preferred because they pay

weekly, not monthly. 4. Students who are studying through the private hospitals

work in their off time for extra money. The students may work three shifts a month to

subsidise their studying (Seanda Health Care: Service Level agreement, 2013:3).

Agency work has advantages, even though nurses find it problematic.

5

1.2 PROBLEM STATEMENT

Nurses doing agency work experience problems such as lack of orientation to the

unit; inability of staff to plan adequately; negative impact of nurse-patient

relationships; lack of teamwork and support; and a decreased sense of belonging

among agency staff.

Agency staff are not orientated adequately by the hospitals and the agency itself;

they are unfamiliar with the policies and procedures of the establishment in which

they may be working and this could decrease quality of care. Agency nurses often

display lack of knowledge about policies, regulation, potential for medication errors, a

need for constant supervision, and charting errors. They receive complaints from

residents and families that disrupted quality care. There is a decline in staff morale

and a decrease in teamwork among agency nurses (Manias et al., 2003:459).

Agency staff are not involved in in-service training offered by the hospitals, as they

are not part of the permanent staff. Training might be seen as too expensive and as

not cost effective for employers to train an agency staff member as such staff may

move to other hospitals or other agencies. Agency staff furthermore may not be

competent nurses and may have little experience in the situations in which they are

placed in spite of having the correct qualifications. Nurses that are newly qualified

and have little experience often work through the agency to gain experience. These

nurses may find themselves in stressful situations where there may be little guidance

concerning procedures when they do not have adequate experience to deal with

challenges correctly. This could lead to incidents and litigation involving both the

nurse and the institution.

Another problem is that staff is often called for duty without adequate time to plan

and prepare themselves for work. Theses nurses may have worked in a similar ward

but not the actual ward in which they are placed due to the shortage of staff and

urgency of needing the staff. This puts patients at risk as mistakes may then be

made. At times, booking is not done in advance and night staff may not have

adequate time to rest before working. The staff may therefore be tired and this will

negatively influence the care delivered; this may lead to an increase in incidents and

6

place the patients at risk. When the workload decreases through wards discharging

patients, agency staff are sent home and are only paid per hour worked, which can

influence agency staff pay and make it difficult to plan financial commitment in their

personal life. Cancelling of off duty on short notice affects the agency nurse and the

hospitals equally: it may influence their sense of responsibility and accountability as

professionals and health care providers. The agency staff may already have got

ready for work, paid transport fees to get to work, and declined other work in the

expectation of already having to work. In the case of the hospital, if the agency staff

cancel at a late stage, the ward in which she was due to work is left short-staffed,

with the ward not having adequate time to replace the staff member with a

competent staff member. For the agency nurse, the unpredictability and uncertainty

of the work supply is seen as the main disadvantage (Ball & Pike; 2006:7).

The nurse-patient relationship is negatively impacted when continuity of nursing care

is broken and this would influence the delivery of quality care. As patients are

exposed to different staff members from day to day as agency staff change, it does

not encourage a patient-staff relationship and disturbs the continuity of care

rendered to the patient (Manias et al., 2003:459).

Teamwork is affected as new nurses often have to work together without having

been able to establish a working relationship to enhance teamwork. The workload

and stress of working in health care establishments require cooperation and

collaboration to achieve thorough teamwork. Teamwork is established when

members of the staff work together for a period and develop an understanding of

each other’s skills and abilities and therefore are able to help and trust one another.

When new staff is used continuously, this trust and the relationships that develop

teamwork are not there. This understanding is very important for emergencies. Good

quality care is associated with nursing teamwork, which may suffer if ward

workforces are destabilised by temporary staff (Hurst & Adam, 2011:289).

Agency staff members experience a poor sense of belonging as they move from one

ward or even one hospital to another, therefore, commitment and loyalty may be

affected and this may influence the communication between staff from different

shifts. Negative experiences with agency work affect the patient, nurses and hospital

7

costs. It was therefore seen as important that the experiences of agency nurses be

documented in order to make recommendations for improving working conditions of

this category of nurses.

1.3 AIM OF STUDY

The aim of this study was to describe the experiences of the agency nurse with

regard to placement in the private hospitals in East London in the Eastern Cape.

1.3.1 Research Question

The research questions that guided this study were:

What are the experiences of the agency nurses with regard to their placement in the

private hospitals in East London, Eastern Cape?

What can be done to enhance experiences of agency staff in private hospitals in

East London in the Eastern Cape?

1.3.2 Research Objectives

The objectives set out for this study were:

To explore and describe the experiences of the agency nurses with regard to

their placement in Private Hospitals in East London, in the Eastern Cape

To make recommendations to enhance the use of agency staff in private

hospitals in East London, in the Eastern Cape.

8

1.4 SIGNIFICANCE OF THE STUDY

This study will provide insight in the use of agency staff. Exploring and describing the

experiences of the agency nurse within the private hospitals in East London may

provide a better understanding of this workforce and lead to recommendations

improve, the relationships and communication between the agencies, nurses,

hospitals and the utilization of agency nurses, therefore improve quality care for the

patients

1.5 CONCEPTUAL FRAMEWORK

A conceptual theoretical framework is the foundation of a study. Not every study is

based on a theory or conceptual model, but every study has a framework (Polit &

Beck; 2006:155). Conceptual frameworks (theoretical frameworks) are a type of

intermediate theory that attempts to connect to all aspects of inquiry.

Conceptual frameworks can act like maps that give coherence to empirical inquiry.

(en.wikipedis.org/conceptual framework accessed on the 26 March 2013)

A conceptual framework is used in research to outline possible courses of action or

to present a preferred approach to an idea or thought.

The conceptual framework in this study is based on the relationships between

agency nurses, permanent nurses, the patient, the agency and the private hospital.

Each concept is linked and influenced by the actions and relationship between each

other.

9

PPP

Figure 1: Conceptual framework for the study

Agency Nurse

Manais et. al., ( 2003:458) describes agency nurse as those who “have their

working life organised by a private contractor, known generally as an agency, to

carry out work within any number of hospital within any one working week and the

work they do on a contractual or temporary basis.

The agency nurse will then be orientated according to the requirements of that

agency or private hospital. Competency should be established by the agency.

LLL NK

PATIENT

PRIVATE

HOSPITALS

PERMANENT

STAFF

PATIENT NURSING

AGENCY

AGENCY NURSES

10

Once orientated the agency nurse is placed in the private hospital via the agency.

The agency nurse are governed by the policies and procedure of the private hospital.

The permanent nurse are governed by the same policies and procedures, therefore

they are needing to work together. The nurse is governed by Nursing Act 50 of 1978

and would need to function within her scope of practice. The nurse accordingly

accepts responsibility and accountability for his/her actions.

Records of hours worked will be recorded via a time sheet, this is authorized by the

private hospital. The time sheets are collected by the agency and then the agency

will pay the nurses.

The agency nurses works within the private hospital with the permanent staff who

are employed by the private hospital to deliver care to the patient. The relationship

between the agency nurse, permanent nurse, private hospital and the agency itself

will influence the type of care the patient will receive.

Agency

In the South African nursing council, in section 1 of the nursing Act 50 0f 1978

defines an agency as a business which supplies registered nurses or midwives,

enrolled nurses or nursing auxiliaries to any person, organisation or institution,

whether for gain or not and whether in conjunction with any other service rendered

by such business or not. (SANC; 2010: 04)

The agency also forms a formal contract between the staff and themselves; this

would include checking references and previous experience and would check for

correct qualification. The agency is also expected to check that the staff are a paid

up member of SANC and has up to date indemnity (Seanda Healcare service level

agreement: 2013: 2)

The agency has to provide records of hours worked, in which wards the staff

member has worked. From this information, a pay roll will be correlated and an

invoice for the hospital will be drawn up. The nursing agencies interact between the

agency nurse and the private institution with regard to staff required or staff to be

cancelled, if there are incidents to be reported and disciplinary action is needed to be

11

communicated and followed up (Seanda Healthcare, Service level agreement, 2013:

3).

The nursing agency interacts with agency staff concerning allocation of work;

payment for work; follow-up on disciplinary action; competency, orientation and

training; and policies and procedure. Nursing agencies interact with permanent staff

and often with management and the administrative staff with regard to follow up on

training and disciplinary action, requirements of the hospital bookings and

cancellations.

Private Hospitals

Private hospitals are defined as “private for profit, a unit where the staffs delivering

health service are recovered from fees for service” (Collier, 2011:9).

The private Hospitals abide by the same regulations as the Agency; a service level

agreement is also signed and the hospital can end the relationship with the agency if

they do not comply with the Service Level Agreement (SLA, 2013:1).

The private hospitals may set standards according to the service level agreement for

the agency. The agency nurse follows the private hospital’s policies and procedures.

The private hospital monitors the competency of the agency nurse and can accept or

reject placement of the agency nurse. Therefore, communication between the private

hospital, agency and staff is important to provide understanding of policies and

procedures.

According to the Basic Conditions of Employment Act, the temporary employment

service and the client are jointly and severally liable if the temporary employment

service, in respect of any employee who provides services to that client, does not

comply with this Act (Basic Conditions of Employment Act, 1997:96).

Permanent staff members

These are the staff members who are permanently employed by the Private Health

care hospital.

12

The permanent staff needs to work together with an agency staff member to provide

the service for their patients. They often are required to orientate agency staff or help

when the agency’s nurses are not familiar with the hospital’s policies and

procedures.

The permanent staff is also governed by the same South African Nursing Council

acts, Basic Conditions of Employment Act and the policies of the institution.

Evidence of reliable and continuous internal and external communication systems

and networks is essential to facilitate quality care for the patient (Muller, 2001:27);

permanent staff should therefore be able to provide the agency staff with information

on the correct policies and procedures of the private health institution and ensure

that correct handover takes place between the agency staff and permanent staff

members.

Patient

The patient is the person who receives treatment from both agency and permanent

staff within the private hospital and who may feel the effect if these do not work well

together.

All patients have patient rights and this includes the right to quality care by both. The

agency nurse and the permanent nurse therefore need to work together for the

benefit of the patient. Many South Africans have experienced a denial or violation of

one of their fundamental human rights, which is the right to health care services. To

ensure the realisation of this right, the Department of Health is committed to uphold

the right to access of health care through the proclamation of the Patients’ Right

Charter, which is written into the Constitution of the Republic of South Africa (Act No.

108 of 1996).

The private sector is required to uphold this right, therefore it is necessary to ensure

that quality care is delivered in their hospitals.

The rights enshrined in the Charter include; a healthy and safe environment;

participation in decision-making; access to healthcare; knowledge of one’s health

insurance/medical aid scheme; choice of health services; to be treated by a named

13

health care provider; confidentiality and privacy; informed consent; refusal of

treatment; to be referred for a second opinion; continuity of care; and the right to

complain about health services (Act No. 108 of 1996). For these rights to be upheld,

the private hospitals will need to ensure that the nurses working in the hospitals are

competent and qualified. This would include responsibility to ensure that the agency

nurses are able to function at their best to deliver quality care. Further, the Batho

Pele principles were developed in alignment with the Constitutional rights to ensure

acceptable policy and legislative frameworks for ensuring quality service delivery

within the Health Services. There are eight principles: the first is consultation;

followed by setting service standards; increasing access; ensuring courtesy;

providing information; openness and transparency; redress; and value for money.

These principles add to the patients’ rights charter and the private hospitals will need

to ensure that their nurses provide information; act courteously; practise openness

and transparency; and maintain a high standard of service. The agency nurses will

need to be trained and to work with the hospital to ensure these principles are

upheld.

1.6. DEFINITION OF TERMS

For the purpose of this study, these following definitions will be use:

1.6.1 Nursing Agency

A nursing agency means a business which supplies registered nurses or midwives or

enrolled nurses or nurse auxiliaries to a person, organisation or institution, whether

for gain or not, and whether in conjunction with any other service rendered by such

business or not (Nursing Act No. 50 of 1978, clause 1 (ix), as amended).

For this study, nursing agency is a business that employs agency staff and places

them in the private hospitals.

14

1.6.1 Registered Nurse

This is a nurse who is educated and competent to practise comprehensive nursing;

assume responsibility and accountability for independent decision making in such

practice; and is registered and licensed as a professional nurse under the Nursing

Act (SANC, Nursing Act 2005, No. 33 of 2005).

For this study, the definition of a registered nurse is a competent person who can

practise comprehensive nursing.

1.6.1 Enrolled Nurse

An enrolled nurse is a person who, having obtained a 2-year diploma, is educated “to

practise basic nursing in the manner and to the level prescribed” – according to

relevant legislation and regulations (SANC, Nursing Act 2005, No. 33 of 2005). For

this study, it defines a nurse who has studied nursing for two years diploma and is

registered as a staff nurse.

1.6.4 Enrolled nursing assistant

An enrolled nursing assistant is a person who has obtained a 1-year diploma, to

practise basic nursing in the manner and to the level prescribed by the relevant

legislation and regulations. The Nursing act states “An enrolled nursing assistant

shall carry out such nursing care as his enrolment permits, under the direct or

indirect supervision or direction of a registered nurse or an enrolled nurse or, where

applicable, under the direct or indirect supervision of a medical practitioner or a

dentist or on his direction or written or verbal prescription” (SANC, Nursing Act 2005,

No 33 of 2005).

15

For this study, an enrolled nursing assistant is defined as a nurse who has studied

for one year, is registered as an enrolled nurse and works under supervision of the

registered nurse and enrolled nurse.

1.6.5 Agency Nurse

Agency nurses are those nurses who “have their working life organised by a private

contractor, known generally as an agency, to carry out work within any number of

hospital within any one working week (Manias et al., 2003:269).

For his study, an agency nurse is a registered nurse, an enrolled nurse or an

enrolled nursing assistant who is employed by the agency but works in the private

hospital.

1.6.6 Private hospitals

Private healthcare institutions are defined as “private for profit, a unit where the staff

delivering health service are recovered from fees for service” (Collier, 2011:9).

For this study, private hospitals are institutions that are managed privately and

function on a profit basis in East London in the Eastern Cape.

16

1.7 CHAPTER OUTLINE

Chapter 1: Introduction and problem statement

Chapter 2: Research Methodology

Chapter 3: Data collection, data analysis and interpretation

Chapter 4: Conceptualisation

Chapter 5: Discussion, conclusion and recommendations

1.8 CONCLUSION

Due to the increased use of agency nurses, this research explores the experiences

of the agency nurse placement in the private hospitals, to gain a better

understanding of this workforce with the intent of identifying strategies that could

improve the use of this type of workforce. This chapter deals with the introduction

and background to this study, the problem statement, the aim of the study and its

objectives, the research question and the significance of the study, as well as the

conceptual framework and chapter outlay.

17

CHAPTER 2: RESEARCH METHODOLOGY

2.1 INTRODUCTION

The previous chapter was focused on describing the background and the problem

statement for the study.

The purpose of this chapter is to describe the research methodology that was

applied to identify the experiences of the agency nurses with regard to their

placement in private hospitals. Brink (2008:111:191) defines methodology as a

method that concentrates on the development of the research instrument, the

evaluation of the instrument and the methods used to investigate the phenomenon,

the research plan. In this chapter, the researcher therefore describes the aim and

objectives, the research design, population, sample and instrument used to gather

the data and analysis of data in the study.

2.2 AIM OF STUDY

A research aim or purpose is a clear, concise statement of the specific goal or aim of

the study, which comes from the research problem or research statement (Burns &

Grove, 2009:85)

The aim of this study is to explore and describe the experiences of the agency nurse

regarding the placement in the private hospitals in East London, Eastern Cape.

2.2.1 Research question

A research question is defined as a concise, interrogative statement developed to

direct studies that are focused on description of variables, examination of

relationships among variables, determination of difference between two or more

18

groups and prediction of dependent variable using independent variables (Burns &

Grove, 2009:750)

The questions that guided the study were:

What are the experiences of the agency nurses with regard to their placement in the

Private Hospitals in East London, Eastern Cape?

What can be done to enhance experiences of agency nurses in Private Hospital in

East London in the Eastern Cape?

2.2.2 Research objectives

A research objective is defined as a clear, concise, declarative statement that is

expressed to direct a study and is focused on identification and description of

variables or determination of the relationships among variables or both (Burns &

Grove, 2009:749)

The objectives set out for this study are:

To explore and describes experiences of the agency nurses regard to their

placement in the Private Hospitals in East London, Eastern Cape.

To describe recommendations for enhance the placement of agency nurses in

the Private hospitals in East London, Eastern Cape.

2.3 RESEARCH DESIGN AND METHODS

Brink (2008:111:191) defines methodology as a method that concentrates on the

development of the research instrument, the evaluation of the instrument and the

methods used to investigate the phenomenon – the research plan. A qualitative

approach with an exploratory and descriptive design was used in this study.

19

2.3.1 Research Approach

Qualitative research is a systematic, interactive, subjective approach used to

describe life experiences and give them meaning (Burns & Grove, 2009:23). Babbie

and Mouton adds that qualitative research is a non-numerical examination and

interpretation of observations for discovering meaning (Babbie and Mounton:

2010:646).

The research approach for this study was qualitative as the aim was to explore and

describe the experiences of the agency nurses and to obtain meaning from their

experiences.

2.3.2 Research Design

Polit and Beck (2006:207) state that a research design is a complete plan of how you

gather data to answer the research question. Burns and Grove (2009:553) and

Babbie and Mouton (2010:74) agree that a research design is a “blueprint for

conducting research”. It capitalises on the control over various factors, which may

affect the validity of the findings: The research design directs the planning and

implementation of the study to achieve the intended goal (Burns & Grove, 2009:553).

An exploratory design investigates the full nature of the phenomenon, the manner in

which it is manifested, and the other factors to which it is related. Exploratory

research explores the dimensions of a phenomenon or develops or refines

hypotheses about relationships between phenomena (Polit & Beck, 2004:20, 718).

Descriptive design is designed to gain more information about the characteristics of

the study and to give a better understanding of the situation as it occurs (Burns &

Grove, 2009:696).

20

This research approach was Qualitative and the research design was exploratory

and descriptive in that the experiences of the agency nurses placed in the private

hospitals were explored to gain understanding of their experiences in private

hospitals in East London, Eastern Cape.

2.4 POPULATION AND SAMPLING

2.4.1 Population

In research, the population comprises all the elements that meet certain criteria for

inclusion in a given universe; these elements could be individuals, objects or

substances. The individual units known as elements could then be referred to as

subjects (Burns & Grove, 2009:745). According to De Vos, Strydom and Delport,

(2002:199), the population is the totality of persons, events, organisations, units,

case records or other sampling units with which the research problem is concerned.

The population of this study consisted of agency nurses of all categories –

professional nurses, enrolled nurses and enrolled nursing assistants – working in the

private hospitals through the agency on a full-time or part time basis for more than

six months. The agency nurses work for one of the nursing agencies in the East

London area. The population size was the 616 nurses in total, who were on the

database, working for the agency at the time of the research. Enrolled nursing

assistants (ENA) provided a population size of 191, Enrolled nurses (EN) made up

174 and registered nurses (RN) were 251 in number.

2.4.2 Sampling

Sampling is defined by selecting a group of people, or elements, with which to

conduct a study, while the sample defines the selected group or elements (Burns &

Grove, 2009:341). The researcher studies the sample in an effort to understand the

21

population from which it was drawn (De Vos et al., 2002:199). A sampling plan is the

process of making the sample selection (Burns & Grove, 2009:341). Sampling is the

process of selecting observations (Babbie & Mouton, 2001:164). According to Burns

and Grove (2009:355,) purposive sampling is used when subjects are consciously

selected to be included in the study.

Purposive sampling was used to select participants for this study. The participants

needed to have worked for more than six months and needed to have been, actively

working in the private hospitals recently. Different categories of staff were

purposefully chosen to include all categories of staff.

The researcher obtained permission from a nursing agency to conduct the research

with the staff working for the agency. The researcher purposefully selected six ENAs,

six ENs and six RNs to participate in this study. The researcher choose 6

participants per category as a starting point because the number needed to obtain

saturation was unknown. The call centre operator employed by the agency contacted

the agency nurses to obtain permission for the researcher to phone the agency staff.

The researcher then contacted the selected participants to make appointments for

the interview. Inclusive criteria were that agency staff members needed to have

worked for the agency for at least six months. Participants were selected according

to their availability and consent to take part in the research. In qualitative research,

the sample size is determined by generating data (Burns & Grove, 2005: 358).

Sample size can be determined by identifying when saturation has been reached,

when gathering fresh data no longer gives new insights or ideas or reveals new

properties (Creswell, 2014:89).

Eligibility criteria are criteria that specify the population’s characteristics; it needs to

be inclusive, whether the population possesses those characteristics or does not

have them (Polit & Beck, 2004:290).

22

2.4.3 Criteria for inclusion

Inclusion sample are those characteristics that the subject or element must possess

to be considered part to the target population (Burns & Grove, 2009:542).

In this study, all professional nurses, enrolled nurses and enrolled nursing assistants

working in the private hospital through the agency on a full-time or part-time basis for

more than six months were included.

2.4.4 Criteria for exclusion.

Exclusion criteria are those characteristics that can cause a person or element to be

excluded from the target population (Burns & Grove,2009: 539).

In this study, the following individuals who were employed at the private hospitals

were excluded from the sample:

Caregivers and administration staff working for the agency in the private hospitals.

Agency nurses who had been working for the agency for less than six months.

Agency nursing staff that were not on the active database.

2.5 RESEARCH INSTRUMENT

Instrumentation is a component of measurement in which specific rules are applied

to develop a measuring device or instrument (Burns & Grove, 2009:539).

In this study, a semi-structured interview guide was used to guide the researcher in

conducting the interview. The questionnaire had two sections: Section A required

general information regarding the age, experience and length of time working for the

23

agency; at how many hospitals the agency nurse was working; and how many hours

participants spent working for the agency. Section B was an interview guide with

open-ended questions exploring the staff’s experiences of placement in the Private

Hospitals. Further probing questions were related to the agency nurses’ relationship

within the hospital and the agency; the advantages and disadvantages of working

through an agency; and how they experienced training. The interview guide was

designed in line with the objectives of the study. The researcher, being employed by

the private hospital and nursing agency, used her own experiences and knowledge

to develop the semi-structured interview guide. The supervisor then validated the

interview guide.

2.5.1 Pre Test

A pre test is a smaller version of a proposed study undertaken to refine the

methodology. The purpose of doing a pre test is to determine whether the study is

feasible, to refine an intervention or a measurement method. It is a data collection

tool in the data collection process (Burns & Grove, 2009:44). A pre test was

conducted on one participant. No problems were identified; the participant

understood the questions and gave relevant information regarding experiences while

working in the private hospital. The participants were selected from the names drawn

initially and interviews were conducted and audio taped. These were then

transcribed. The data were used to determine whether there were problems with the

interview guide and relevant data was obtained. The recorded interview was sent to

an independent researcher to confirm that the researcher had adequate interview

skills and that the interview was conducted correctly and respectfully. Consent was

obtained from the all participant.( refer to appendix 6)

24

2.6 DATA COLLECTION

Data are defined as pieces of information that are collected during a study and data

collection refers to the precise, systematic collection of information relevant to the

research purpose (Burns & Grove, 2009:733). Interviews involve verbal

communication between the researcher and the subject, during which information is

provided to the researcher (Burns & Grove, 2009:396). Interviews are frequently

used in exploratory and descriptive research. Interviews that range between

structured and unstructured are referred to as semi-structured (Brink, 2008:151).

Semi-structured interviews are used to gain a detailed picture of a participant’s

beliefs about, or perception or accounts of, a particular topic. The researcher is able

to follow up particular interesting avenues that emerge in the interview, and the

participant is able to give a fuller picture (De Vos, 2002:303).

The data collection for this study was done by means of in-depth, semi-structured

interviews that were recorded and transcribed verbatim. The researcher conducted

the interviews. The researcher had worked for the agency in the previous year and

therefore knew some of the participants. At the beginning of the interview, the

researcher inquired whether this was an issue and reassured the participant that, as

the researcher no longer worked for the agency, what was said in the interview

would be confidential. Consent was obtained from the participants, who volunteered

to be part of the study. The interview took place in a neutral place chosen by the

participants. The length of each interview was about 45 minutes. The participants

were interviewed over a period of eight weeks due to the availability of the

participants and each interview was conducted, transcribed and meaning was

attached to each interview. The participants understood English, therefore the

interviews were conducted in English. The researcher provided clarification when

necessary. The interviews followed a similar pattern. Participants were made to feel

welcome; the procedure of gathering data was explained and their rights clarified.

Section A of the interview, which dealt with demographic data was completed on the

questionnaire. This helped the researcher to establish a relationship with the

participant and to put her at ease. The tape recorder was put in place and turned on

for section B of the interview. The researcher ensured, before the interview, that the

25

tape recorder had sufficient time to complete the interview. The open-ended

question, “How do you as an agency nurse experience working in the private

hospitals, here in East London?” was used to start section B. Depending on what

information the participant shared, probing questions were asked. Probing questions

were related to the advantages and disadvantages of working through the agency;

the teamwork experienced; and whether the participants felt supported. It ended

asking a question related to the participant’s suggestion on what measure could be

implemented to improve placement of agency nurses and time was allowed to think

of more information that could be discussed. The researcher transcribed the

interview verbatim for accuracy. The researcher had explained to the participant that

field notes would be taken while the participant was talking. Field notes on

expression and non-verbal cues were therefore taken by the researcher during the

interview.

In this study, saturation was reached after 13 of the 18 participants had been

interviewed. The 13 participants consisted of five Registered nurses, four Enrolled

nurses and four Enrolled nursing assistants who had been interviewed when

saturation was reached.

2.7 DATA ANALYSIS

Data analysis is a technique used to reduce, organise and give meaning to data

(Burns & Grove, 2009:536). Data in qualitative research is non-numerical and

involves an examination of words (Brink, 2008:184). According to Creswell, the

purpose of data analysis is to make sense out of text, which involves segmenting

and taking apart the data and then putting it together again. The first step in

analysing data is to organise the information; this involves transcribing the interviews

and field notes. Step 2 involves reading through the data; this provides a general

sense of the information and opportunity to reflect on the meaning. Step 3 involves

starting to code all data. This is the process of organising the data by bracketing

chunks and writing a word representing a category in the margin. Step 4 then

involves using the coding to generate a theme. In Step 5, the themes are

26

represented in the qualitative narrative. The final step involves interpreting the

findings and results (Creswell, 2014:195). A theme is described by Polit and Beck as

an abstract entity that brings meaning and identity to a current experience and

variant manifestations (Polit & Beck, 2004:578). The steps followed according to

Creswell are presented in Chapter 2, Table 2.1.

Table 2.1: Creswell’s steps in data analysis

Creswell’s steps in data analysis

Stage of data

Analysis

Analysis process

One Organise data

Two Read through data to gain a sense of the data

Three Code the data by bracketing

Four Generate a theme

Five Interpreting the findings and results

In this study, the interviews were transcribed by the researcher as they were

conducted. This enabled the researcher to follow steps 1 and 2 and gathering an

understanding of the data. The researcher transcribed the information and then read

and reread the transcriptions and to gain further understanding as to the meaning

and tone of what was said. Then the researcher bracketed the data into similar

groups of meaning. The next step was to code the data and identify themes and sub-

themes, for instance data related to the agency nurses gaining experience through

their work in the hospitals. Further themes were identified and the relationships

between them linked. For example, the theme related to gaining experience through

working in the private hospitals was connected to the theme related to the difference

between the private and public sector as different technology is used. The last step

was to intrepret the data and make recommendations regarding the placement of the

agency nurses in order for them to function at their best. The electronic system of

AtlasTi was used to aid the data anaysis. The interviews were transcribed into

AtlasTi and then coded on the system. This helped the researcher to organise the

27

information. The taped interviews and transcriptions were given to an indepented co-

coder who checked the data for accuracy. The co-coder checked the themes

generated and discussed the findings with the researcher. Table 2.2 illustrates some

responses from participants and the meanings allocated to these by the researcher.

Table 2.2: Example of significant statements and formation

of meaning

Example of significant statements and formation of meaning

Excerpts from interviews Formation of meaning

It has been very good to for me right

because I have never work in the private

hospital and also in the unit I worked I

am working now I have never worked in

it so it just gives me much experience

and knowledge and I quite interested in

working there so interesting.

(Participant 4)

Gains experience in private

Different to where she has

worked before. It is new,

gains knowledge and experience, finds it

interesting.

I don’t mind wearing the white shirt but

then I don’t like someone who is going to

point at me cause, ja, we are supposed

to wear white shirt or any shirts that are

not permanent they are supposed to

wear their uniform but basically they like

their uniform but we need to work

together as a team there is nothing

wrong that I am an agency at and she

permanent or she is permanent so we all

do our job it’s not like the agency staff sit

and do nothing.

(participant 6)

Feels the different uniforms create

differences.

Shows she is different physically, it

makes her stand out.

Believes it influences respect and self-

confidence

Teamwork is affected negatively.

Believes she is able to do her job but not

recognised for her ability; only seen as

an agency nurse.

28

Yes a long time, yes it is a long time if

I get a job somewhere I will go at any

time cause I can’t stay like this even to

go to school I want to go to school.

(Participant 12)

Would like a permanent job.

Disappointment at not being made

permanent.

Would take a permanent post anywhere.

Feels she has worked a long time as an

agency nurse. Disappointed.

Wants to improve herself.

2.8 ETHICAL CONSIDERATIONS

According to the National Health Act, (2003: 73) research and ethics committees in

the field of health care are a legal requirement in South Africa. The researcher has

the responsibility of conducting the research in an ethical manner.

Ethical considerations were applied according to the principles of permission,

consent, beneficence, justice, privacy, confidentiality, anonymity and self-

determination. These principles are based on the human rights that need to be

protected in research (Brink, 2008:31).

Principles of permission

Permission to participate in a study concerns agreement by parents or guardians to

the participation of their child or ward in research (Burns & Grove, 2009:713)

This principle was respected by the following: The call centre operator of the agency

was phoned and asked for permission to give the researcher the participant’s phone

number. The researcher then acquired permission from the participant to take part in

the study. All participants volunteered. The agency by which the nurses are

employed granted the researcher permission to conduct the study with their

employees.

29

Consent

It is essential to obtain informed consent to conduct ethical research on human

subjects, (Burns & Grove, 2009:201). Consent involves an agreement to participate

in a study (Burns & Grove, 2009:693). Adequate information regarding the research

needs to be given to the participant and they need to be capable of understanding

the information; free choice is allowed to the participate (Polit & Beck; 2004: 151)

In this research, the participants were fully informed of the purpose of the study and

were given a choice to participate or not. The reason for the study and all principles

were explained to the participant before they were asked to give written consent. The

participants were given information in writing concerning the study and written

consent was obtained for audio and written recording of the interview. (refer to

appendix 5 and 6)

Beneficence

The principle of beneficence has to do with the welfare of participants; the

researcher must undertake to do no harm and is encouraged to do good (Burns &

Grove, 2009:680). All ethical principles of respect for beneficence were upheld in

this study as the participants, the agency or the hospital in which they work suffered

no harm. The researcher has an ethical responsibility to recognise and protect the

rights of the individuals and groups taking part in the research. Therefore, in this

study, the researcher had a responsibility to the agency nurses who were

interviewed, the private hospitals and the agencies for which the nurses were

working. Ethical approval was sought from the Fort Hare University research ethics

committee.

Justice

The principle of justice states that the participants should be treated fairly (Burns &

Grove, 2009:706). Human rights concern claims that have been justified in the eye of

an individual or a group (Polit & Beck, 2004:151). In this study, all participants were

treated fairly; all were given a choice concerning whether to volunteer to participate

or to withdraw. If participants found it difficult to be interview this was respected by

the researcher and another participant was found.

30

Privacy

Privacy is defined as the freedom that a participant has to determine the time, extent

and general circumstances under which private information will be shared with or

withheld from others (Burns & Grove, 2009:715). The right to privacy was abided by

as the interviews were done one on one. Participants were given the choice to refuse

to answer certain questions and only divulged what they were able to share

comfortably.

Confidentiality

Confidentiality has to do with the management of private data in research so that

participant’s identities are not linked to their responses (Burns & Grove, 2009:693).

In this study the participant’s name, the private hospital in which the participant

worked and the agency for which the participant worked were kept confidential.

Information concerning the participant was not linked to a name, the hospital or the

agency. Participants were allocated a number, the hospital was known as the private

hospital and the nursing agency was known as the agency.

Anonymity

Anonymity requires that the participant’s identity cannot be linked to the participant’s

responses (Burns & Grove, 2009:688).

A number was assigned to each participant and all data relating to the participant

were labelled with the number assigned to the participant. The data were processed

anonymously. The principle of anonymity was enforced and confidentiality was

maintained. (Refer to appendix 9)

Self-determination

Self-determination is based on the ethical principle of respect for others, which states

that participants have the ability to control their own destiny. The right to self-

determination is violated through coercion, covert data collection and deception in

the research process (Burns & Grove, 2009:722). In the study, all participants were

31

treated with respect, all participants voluntered to take part in the study, the

participants were able to choose the time and place when and where the interview

took place. Data were collected openly and were transparent. The research process

was followed and monitored by the supervisor.

2.9 TRUSTWORTHINESS

The researcher ensured the trustworthiness of the study by using the criteria of

credibility, transferability, dependability and conformability proposed by Lincoln and

Guba (1984). These criteria and their application in the current study are presented

graphically in Chapter 2. Table 2.3.

Table 2.3: Strategies of trustworthiness

Strategy Criteria Application in this study

Credibility Supervisor in this study is experienced.

The researcher in this study was

previously working as a manager for an

agency where placement of agency

nurses was done, for more than 5

years.

The researcher was previously working

in the private hospitals utilising agency

nurses, however the researcher

conducted the study in a different

capacity, which is a researcher from the

University of Fort Hare.

Semi-structured interviews were used

in this study and the transcripts were

32

recorded verbatim.

Triangulation The researcher conducted individual

interviews.

Observation of body language and

facial expression were recorded during

the interview.

Field notes were made by the

researcher during the interview.

The interviews were recorded and

transcribed verbatim.

An in-depth literature review was

conducted from different data sources.

Creswell’s data analysis was used to

analyse the data.

An independent coder analysed the

interviews.

Member checking Follow-up interviews to validate data

were conducted with the participants by

the researcher.

Literature was checked and reviewed

throughout the study.

Peer examination Peer examination of the study was

done while the researcher was

collecting data.

Another researcher examined the pilot

study to check the effectiveness of the

research instrument.

Authority of researcher The researcher attended courses on

research.

The supervisor is very experienced in

research.

Transferability Dense description A qualitative approach with an

33

exploratory and descriptive design was

applied in this study.

The study might be transferred to

exploring experiences of agency nurses

in other areas; could be transferable to

exploring the experiences of the

permanent staff and managers working

in the private hospitals with the agency

nurses.

Convenient sample Convenient sampling was used and

saturation was reached after

interviewing 13 participants.

Dependability Dense description of

research method, theory

generation and

guidelines for use in

practice

Data collection was verified and

authenticated by a researcher from the

University of Fort Hare.

Creswell’s method of analysing of data

was used. Bracketing of thoughts and

ideas was concluded,

The six themes derived from the data

were further discussed and confirmed

with the researcher.

The supervisor reaffirmed the themes

derived.

Triangulation Semi-structured interviews were

conducted

Data collected from these interviews

suggested six themes and themes were

compared to literature.

Themes were co-coded by an

independent coder.

Confirmability Confirmability audit Consensus was reach between the

researcher and the independent coder.

34

Triangulation Semi-structured interviews for exploring

experiences.

An independent coder was used to

confirm the themes.

Literature was compared with data

gathered.

Credibility concerns the compatibility of the constructed realities that exist in the

minds of the respondents and those that are attributed to them (Babbie & Mouton;

2010:276). In this study, the researcher used many different literature sources from

different countries to get to know the data already obtained and compiled it a

literature review. To authenticate the data collected, participants were quoted

verbatim in the transcriptions of the interviews. The researcher verified conclusions

from the collected data with participants to ensure that the interpretations of the data

were correct.

Transferability refers to the extent to which the findings can be applied in other

contexts or with other respondents. Triangulation is described as information

gathered from various sources (De Vos, et al., 2002). In this study, the only method

used to gather data was one-on-one interviews. Triangulation was obtained by,

individual interviews conducted by the researcher. Observation of body language

and facial expression were recorded during the interview. The researcher made field

notes during the interview. The interviews were recorded and transcribed verbatim.

An in-depth literature review was conducted from different data sources. Creswell’s

data analysis was used to analyse the data. An independent coder analysed the

interviews and conferred with the researcher.

The study can be transferred and studied in different context. Other studies can be

conducted in different areas of South Africa and other aspect of agency work can be

research.

With regard to dependability, an inquiry must also provide its audience with evidence

that, if the research were to be repeated with the same or similar respondents in the

same context, its findings would be similar (Babbie & Mouton, 2010:277). In this

35

study, a researcher from the University Of Fort Hare verified and authenticated the

data collected. Analysis of data and themes derived were further discussed and

confirmed with this researcher. The supervisor confirmed the themes derived.

Confirmability concerns the degree to which the findings are the product of the focus

of the inquiry and not of the biases of the researcher (Babbie & Mouton, 2010:278).

Member checking to determine the accuracy of the data means showing the final

analysis of the data to the participants to determine whether the interpretation is

accurate (Creswell, 2014:201). Member checking was done in this study through

follow-up interviews to validate data. Clarifing the bias the resercher brings to the

study will help validate the study (Creswell, 2014:201). Here the researcher did self-

reflection on her ideas and opinions related to the agency nurses. The researcher,

having worked in the private hospitals and having managed an agency, distanced

herself from her own ideas and opinions before each interview was conducted and

during data analysis. The researcher used skills like listening without bias and

probing questions, following the participant’s train of thought. During the interview,

field notes were taken and non-verbal clues were observed.

2.10 CONCLUSION

In this chapter, the goal and objectives were discussed as well as the design,

methodology, population and sampling process was disclosed. The research

instrument was explained and how the pilot study was conducted. Data collection

was discussed and clarification of how trustworthiness was obtained. Creswell’s

steps in data analysis were used to evaluate the data.

In the next chapter, the description of the data analysis and interpretation of the

findings will be presented. In section A, the demographic data is explained and the

themes generated will be described in section B.

36

CHAPTER 3: ANALYSIS AND INTERPRETATION OF

RESEARCH FINDINGS

3.1 INTRODUCTION

In the previous chapter, the goal and objectives of the research were discussed and

the design, methodology, population and sampling process was disclosed. The

research instrument and how the pilot study was conducted were explained. Data

collection was discussed and how trustworthiness was obtained were clarified.

Creswell’s steps in data analysis were used to evaluate the data.

The findings and interpretation of the findings are presented in this chapter. The

researcher has reflected on the experiences of the agency nurses with regard to

their placement in the private hospitals as obtained from the interviews.

Two sections are presented in this chapter: sections A and B. Section A explains the

demographic data of the agency nurses and Section B is focused on the themes

generated. Inductive reasoning was applied to generate the themes. Inductive

reasoning involves drawing conclusions from the collection of empirical facts

whereby facts are moved from fact to general facts (Burns & Grove, 2009:6). An

experience of one nurse was observed, and then combined into a larger or general

statement regarding the experiences of many nurses. Excerpts from the interview

are presented and discussed and the relationship between the data gathered from

the agency nurses placed in the East London Private hospitals is linked to literature

gathered from previous studies.

37

3.2 SECTION A

This section is focused on demographic data concerning the participants in the

study, as presented in Table 3.1.

Table 3.1: Demographic profile of agency nurses

Frequency Percentage

Gender

Male 0 0

Female 13 100

Total 13

Professional registration with SANC

RN 5 38

EN 4 31

ENA 4 31

Total 13 100

AGE

20 – 29 4 31

30 – 39 6 46

40 – 49 3 23

Total 13 100

Year nurses qualified

1991 1 9

1993 1 9

1997 1 9

2000 1 9

2005 1 9

2009 1 9

2010 3 23

2011 1 9

2013 2 15

38

Total 13 100

Years working in the health institutions after qualifying

0 months 6 46

1 - 2 years 2 15

5 years 1 9

12 years 2 15

14 years 1 9

20 years 1 9

Total 13 100

Months and years working for agency

1 - 2 years 7 54

2 - 3 years 5 38

17 years 1 9

Total 13 100

Different hospitals worked in as an agency nurse.

1 8 62

2 3 23

3 2 15

Total 13 100

Nurses working permanently or only working for the agency or both

Permanent employed

and agency work

5 38

Agency work only 8 62

Total 13 100

Hours worked for agency per week

40 7 53

36 1 9

24 1 9

12 4 31

Total 13 100

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In this study five registered nurses, four enrolled nurses and four enrolled nursing

assistants were interviewed. All participants were female.

The ages of the participants varied from 21 years of age to 48 years of age.

The years in the participants qualified for their relevant registrations vary from 1991

to as recent as 2013. The working experience before joining the agency varied

between 20 years’ experience to just qualified. The one participant had worked

through the agency as a student and then as an enrolled nurse. Six of the thirteen

participants had not worked before in another hospital but could only get

employment through the agency. One of the participants had only worked in the

hospitals as a student.

Regarding the number of months or years worked for the agency, the criteria for

inclusion stated that the agency nurse needed to have worked through the agency

for longer than six months. The participants’ years of working for the agency varied

from one year to 17 years. One participant had been working through different

agencies in different hospitals for 17 years. The rest of the participants had been

working from one year to three years.

Regarding the number of different hospitals worked in through the agency, eight of

the participants had only worked in one hospital. Three had worked in two different

hospitals and only two had worked in three different hospitals., The majority of the

participants had therefore only worked in one hospital.

Concerning the number of participants that had permanent jobs, five of the thirteen

participants were employed by another hospital where they work full time, while only

moonlighting in private institutions. Eight of the thirteen participants only worked

through the agency. One of the participants had been a student previously and then

was employed by the hospital as a permanent employee. One participant was

employed permanently by the hospital after working through the agency on a full-

time basis.

Participants who were full-time employees of another institution where they work a

40-hour week, did between 12 hours and 24 hours extra work per month. The

40

participants who only work through the agency work a full 40-hour week for the

agency. They therefore are known as full-time agency staff members.

The ages of the majority of participants ranged from the early 20s to early 40s. The

majority of participants had no previous experience working in a health institution.

The majority of participants had worked for the agency for between one and three

years. The majority of participants were only employed through the agency, working

a 40-hour week and working in one hospital only.

3.3 SECTION B

Six themes emerged from the interviews, namely: reasons for doing agency work;

growth through experience; disappointment of not been made permanent;

challenges encountered by agency nurses; environment of working conditions; and,

lastly, a sense of security.

Sub-themes emerged from the main five themes and categories emerged from the

sub-themes as displayed in Table 3.2. The first sub-themes that emerged from

definite reason for doing agency work included employment opportunities need to

increase financial income and need for flexible working hours. The categories

originating from the need for increase in financial income were overtime and

supplementing student’s income.

The second theme was growth through experience. The sub-themes generated from

this theme were agency nurses gain knowledge while working, training opportunities

for agency nurses and orientation given to agency nurses. The categories for this

theme were learning new technology and knowledge.

The third theme was disappointment of not been made permanent. The fourth theme

was challenges encountered by agency nurses. Here the sub-themes were fear felt

by agency nurses, disparity between permanent and agency nurses, attitudes of

permanent staff and no benefits. The categories were agency nurses work harder,

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feelings related to incidents, uniforms made agency nurses feel discriminated

against and conflict expressed.

The fifth theme was environment of working conditions; the sub-themes were

cleanliness of the physical environment; disparity between private and pu